Suprapubic tubes (SPT) are a vital tool in the management of complex urologic voiding conditions. There are numerous methods of SPT placement, each with pros/cons: peel-away kits are easy to place, but often have small caliber SPTs, that is, 12 or 14 Fr, prone to kinking, that require serial upsizing to achieve the desired caliber; open SPT placements permit an initial large caliber SPT but are more invasive, particularly in obese patients. This video demonstrates a minimally invasive technique for SPT placement in patients with preserved urethral access to the bladder that safely allows for initial, precise placement of large caliber (>20F) catheters using the Nephromax nephrostomy balloon/sheath (NBS-SPT). Technique: A 6″ 17G Tuohy spinal needle is placed percutaneously 3 cm above the pubis (generally in the abdominal crease), 1-2 cm off midline towards the side the patient prefers to keep the drainage bag. The needle is angled to enter the bladder dome in the midline, which is visualized cystoscopically with a full bladder. The angling will allow the catheter to lie flat and decrease kinking. The stylette is removed and a stiff wire is advanced. A 2 cm horizontal skin incision is made. A 24 Fr NBS is advanced into the bladder under vision and inflated to 18 ATM. The balloon is then deflated/removed and the SPT is passed through the sheath into the bladder. Once inflated, the sheath removed and the SPT is secured to the skin. Study: A 10-year retrospective review of NBS-SPT placements at a single institution was performed, analyzing patient characteristics, surgical details, and surgical outcomes. NBS-SPT was attempted 65 times over the study period. The most common indications included acquired/congenital neurogenic bladder (48%) and urinary retention (25%). A simultaneous additional procedure (eg, cytolitholapaxy, bladder neck incision) was performed in 31% of NBS-SPTs. Median body mass index was 29.5 (interquartile range: 25-33.9) and 34% had prior abdominal procedures. Median operative time (NBS-SPT only) was 16 minutes (interquartile range: 14-20). All procedures were successful in placing a catheter 20F. Thirty-day Clavien I/II complication rate was 18% (hematuria n = 3; cellulitis n = 4; early SPT exchange for clogging n = 5); A Clavien IIIb complication occurred in one patient with hematuria requiring fulguration. First SPT exchange in clinic was successful in 95%, with 2 patients requiring replacement under anesthesia. NBS-SPT is a safe and efficient minimally invasive technique for initial, precise placement of large caliber SPT in patients with urethral bladder access.